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08-11-2023 | Hysterectomy

State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth

Published in: Maternal and Child Health Journal | Issue 1/2024

Abstract

Objectives

Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth.

Methods

Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017–2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics.

Results

A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio.

Conclusions for Practice

State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.

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Admon, L. K., Auty, S. G., Daw, J. R., Kozhimannil, K. B., Declercq, E. R., Wang, N., & Gordon, S. H. (2023). State variation in severe maternal morbidity among individuals with Medicaid insurance. Obstetrics and Gynecology, 141(5), 877–885. https://doi.org/10.1097/AOG.0000000000005144CrossRefPubMed

Admon, L. K., Winkelman, T. N. A., Zivin, K., Terplan, M., Mhyre, J. M., & Dalton, V. K. (2018). Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012–2015. Obstetrics and Gynecology, 132(5), 1158–1166. https://doi.org/10.1097/AOG.0000000000002937CrossRefPubMed

American College of Obstetricians Gynecologists, the Society for Maternal-Fetal Medicine, Kilpatrick SK, Ecker JL. (2016). Severe maternal morbidity: Screening and review. American Journal of Obstetrics and Gynecology, 215(3), B17-22. https://doi.org/10.1016/j.ajog.2016.07.050CrossRef

Bailey, Z. D., Feldman, J. M., & Bassett, M. T. (2021). How structural racism works - Racist policies as a root cause of U.S. racial health inequities. The New England Journal of Medicine, 384(8), 768–773. https://doi.org/10.1056/NEJMms2025396CrossRefPubMed

Bailey, Z. D., Krieger, N., Agenor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. Lancet, 389(10077), 1453–1463. https://doi.org/10.1016/S0140-6736(17)30569-XCrossRefPubMed

Bellerose, M., Collin, L., & Daw, J. R. (2022). The ACA Medicaid expansion and perinatal insurance, health care use, and health outcomes: A systematic review. Health Affairs (millwood), 41(1), 60–68. https://doi.org/10.1377/hlthaff.2021.01150CrossRef

Centers for Disease Control and Prevention. (2019). How does CDC identify severe maternal morbidity? Retrieved August 16, 2023, from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm

Chambers, B. D., Erausquin, J. T., Tanner, A. E., Nichols, T. R., & Brown-Jeffy, S. (2018). Testing the association between traditional and novel indicators of county-level structural racism and birth outcomes among Black and White women. Journal of Racial and Ethnic Health Disparities, 5(5), 966–977. https://doi.org/10.1007/s40615-017-0444-zCrossRefPubMed

Chen, J., Cox, S., Kuklina, E. V., Ferre, C., Barfield, W., & Li, R. (2021). Assessment of incidence and factors associated with severe maternal morbidity after delivery discharge among women in the US. JAMA Network Open, 4(2), e2036148. https://doi.org/10.1001/jamanetworkopen.2020.36148CrossRefPubMedPubMedCentral

Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and structural determinants of health inequities in maternal health. Journal of Women’s Health, 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882CrossRefPubMedPubMedCentral

Declercq, E. R., Cabral, H. J., Cui, X., Liu, C. L., Amutah-Onukagha, N., Larson, E., Meadows, A., & Diop, H. (2022). Using longitudinally linked data to measure severe maternal morbidity. Obstetrics and Gynecology, 139(2), 165–171. https://doi.org/10.1097/AOG.0000000000004641CrossRefPubMed

Devakumar, D., Selvarajah, S., Abubakar, I., Kim, S. S., McKee, M., Sabharwal, N. S., Saini, A., Shannon, G., White, A. I. R., & Achiume, E. T. (2022). Racism, xenophobia, discrimination, and the determination of health. Lancet, 400(10368), 2097–2108. https://doi.org/10.1016/S0140-6736(22)01972-9CrossRefPubMed

Dyer, L., Chambers, B. D., Crear-Perry, J., Theall, K. P., & Wallace, M. (2022). The index of concentration at the extremes (ICE) and pregnancy-associated mortality in Louisiana, 2016–2017. Maternal and Child Health Journal, 26(4), 814–822. https://doi.org/10.1007/s10995-021-03189-1CrossRefPubMed

Dyer, L., Hardeman, R., Vilda, D., Theall, K., & Wallace, M. (2019). Mass incarceration and public health: The association between black jail incarceration and adverse birth outcomes among black women in Louisiana. BMC Pregnancy and Childbirth, 19(1), 525. https://doi.org/10.1186/s12884-019-2690-zCrossRefPubMedPubMedCentral

Friedman, A. M., Ananth, C. V., Huang, Y., D’Alton, M. E., & Wright, J. D. (2016). Hospital delivery volume, severe obstetrical morbidity, and failure to rescue. American Journal of Obstetrics and Gynecology, 215(6), 795 e1-e14. https://doi.org/10.1016/j.ajog.2016.07.039CrossRefPubMed

Friedman, A. M., Wright, J. D., Ananth, C. V., Siddiq, Z., D’Alton, M. E., & Bateman, B. T. (2016). Population-based risk for peripartum hysterectomy during low- and moderate-risk delivery hospitalizations. American Journal of Obstetrics and Gynecology, 215(5), 640 e1-e8. https://doi.org/10.1016/j.ajog.2016.06.032CrossRefPubMed

Guglielminotti, J., Daw, J. R., Friedman, A. M., Landau, R., & Li, G. (2023). Medicaid expansion and risk of eclampsia. American Journal of Obstetrics & Gynecology MFM, 5(8), 101054. https://doi.org/10.1016/j.ajogmf.2023.101054CrossRef

Guglielminotti, J., Landau, R., & Li, G. (2021b). The 2014 New York State Medicaid expansion and severe maternal morbidity during delivery hospitalizations. Anesthesia and Analgesia, 133(2), 340–348. https://doi.org/10.1213/ANE.0000000000005371CrossRefPubMed

Guglielminotti, J., Wong, C. A., Friedman, A. M., & Li, G. (2021a). Racial and ethnic disparities in death associated with severe maternal morbidity in the United States: Failure to rescue. Obstetrics and Gynecology, 137(5), 791–800. https://doi.org/10.1097/AOG.0000000000004362CrossRefPubMed

Gyamfi-Bannerman, C., Srinivas, S. K., Wright, J. D., Goffman, D., Siddiq, Z., D’Alton, M. E., & Friedman, A. M. (2018). Postpartum hemorrhage outcomes and race. American Journal of Obstetrics and Gynecology, 219(2), 185 e1-e10. https://doi.org/10.1016/j.ajog.2018.04.052CrossRefPubMed

Healthcare Cost and Utilization Project. (2022). HCUP fast stats: severe maternal morbidity (SMM) among in-hospital deliveries. Retrieved August 16, 2023, from https://datatools.ahrq.gov/hcup-fast-stats?count=3&tab=hcupfsse&type=subtab

Howell, E. A., Brown, H., Brumley, J., Bryant, A. S., Caughey, A. B., Cornell, A. M., Grant, J. H., Gregory, K. D., Gullo, S. M., Kozhimannil, K. B., Mhyre, J. M., Toledo, P., D’Oria, R., Ngoh, M., & Grobman, W. A. (2018). Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. Obstetrics and Gynecology, 131(5), 770–782. https://doi.org/10.1097/AOG.0000000000002475CrossRefPubMed

Hoyert, D. L. (2020). Maternal mortality rates in the United States, 2020. Retrieved August 16, 2023, from https://stacks.cdc.gov/view/cdc/113967

Jahn, J. L., Chen, J. T., Agenor, M., & Krieger, N. (2020). County-level jail incarceration and preterm birth among non-Hispanic Black and white U.S. women, 1995-2015. Social Science & Medicine, 250, 112856. https://doi.org/10.1016/j.socscimed.2020.112856CrossRef

Janevic, T., Zeitlin, J., Egorova, N., Hebert, P. L., Balbierz, A., & Howell, E. A. (2020). Neighborhood racial and economic polarization, hospital of delivery, and severe maternal morbidity. Health Affairs (millwood), 39(5), 768–776. https://doi.org/10.1377/hlthaff.2019.00735CrossRef

Kaufman, E. (2020). The prisoner trade. Harvard Law Review, 133(6), 1815–1878.

Kleinman, L. C., & Howell, E. A. (2022). Equity and the hazard of veiled injustice: A methodological reflection on risk adjustment. Pediatrics. https://doi.org/10.1542/peds.2020-045948GCrossRefPubMed

Krieger, N., Kim, R., Feldman, J., & Waterman, P. D. (2018). Using the Index of Concentration at the Extremes at multiple geographical levels to monitor health inequities in an era of growing spatial social polarization: Massachusetts, USA (2010–14). International Journal of Epidemiology, 47(3), 788–819. https://doi.org/10.1093/ije/dyy004CrossRefPubMed

Liu, S. Y., Fiorentini, C., Bailey, Z., Huynh, M., McVeigh, K., & Kaplan, D. (2019). Structural racism and severe maternal morbidity in New York State. Clinical Medicine Insights: Women’s Health, 12, 1–8. https://doi.org/10.1177/1179562X198547CrossRef

Lukachko, A., Hatzenbuehler, M. L., & Keyes, K. M. (2014). Structural racism and myocardial infarction in the United States. Social Science and Medicine, 103, 42–50. https://doi.org/10.1016/j.socscimed.2013.07.021CrossRefPubMed

Luke, B., Brown, M. B., Liu, C. L., Diop, H., & Stern, J. E. (2018). Validation of severe maternal morbidity on the US certificate of live birth. Epidemiology, 29(4), e31–e32. https://doi.org/10.1097/EDE.0000000000000828CrossRefPubMedPubMedCentral

MacDorman, M. F., Thoma, M., Declcerq, E., & Howell, E. A. (2021). Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 20162017. American Journal of Public Health, 111(9), 1673–1681. https://doi.org/10.2105/AJPH.2021.306375CrossRefPubMedPubMedCentral

Malat, J., Mayorga-Gallo, S., & Williams, D. R. (2018). The effects of whiteness on the health of whites in the USA. Social Science and Medicine, 199, 148–156. https://doi.org/10.1016/j.socscimed.2017.06.034CrossRefPubMed

Mari, K. E., Yang, N., Boland, M. R., Meeker, J. R., Ledyard, R., Howell, E. A., & Burris, H. H. (2023). Assessing racial residential segregation as a risk factor for severe maternal morbidity. Annals of Epidemiology, 83, 23–29. https://doi.org/10.1016/j.annepidem.2023.04.018CrossRefPubMed

McGhee, H. C. (2021). The sum of us: What racism costs everyone and how we can prosper together. One World.

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Mayes, N., Johnston, E., Syverson, C., Seed, K., Shapiro-Mendoza, C. K., Callaghan, W. M., & Barfield, W. (2019a). Vital signs: Pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. Morbidity and Mortality Weekly Report, 68(18), 423–429. https://doi.org/10.15585/mmwr.mm6818e1CrossRefPubMedPubMedCentral

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019b). Racial/ethnic disparities in pregnancy-related deaths - United States, 2007–2016. Morbidity and Mortality Weekly Report, 68(35), 762–765. https://doi.org/10.15585/mmwr.mm6835a3CrossRefPubMedPubMedCentral

Sun, E. P., Guglielminotti, J., Chihuri, S., & Li, G. (2022). Association of Medicaid expansion under the affordable care act with perinatal care access and utilization among low-income women: A systematic review and meta-analysis. Obstetrics and Gynecology, 139(2), 269–276. https://doi.org/10.1097/AOG.0000000000004647CrossRefPubMed

Sundaresh, R., Yi, Y., Harvey, T. D., Roy, B., Riley, C., Lee, H., Wildeman, C., & Wang, E. A. (2021). Exposure to family member incarceration and adult well-being in the United States. JAMA Network Open, 4(5), e2111821. https://doi.org/10.1001/jamanetworkopen.2021.11821CrossRefPubMedPubMedCentral

Taylor, J. K. (2020). Structural racism and maternal health among Black women. The Journal of Law, Medicine & Ethics, 48(3), 506–517. https://doi.org/10.1177/1073110520958875CrossRef

Vilda, D., Hardeman, R., Dyer, L., Theall, K. P., & Wallace, M. (2021). Structural racism, racial inequities and urban-rural differences in infant mortality in the US. Journal of Epidemiology and Community Health, 75(8), 788–793. https://doi.org/10.1136/jech-2020-214260CrossRefPubMed

Wallace, M. E., Crear-Perry, J., Green, C., Felker-Kantor, E., & Theall, K. (2019). Privilege and deprivation in Detroit: Infant mortality and the index of concentration at the extremes. International Journal of Epidemiology, 48(1), 207–216. https://doi.org/10.1093/ije/dyy149CrossRefPubMed

Wallace, M., Crear-Perry, J., Richardson, L., Tarver, M., & Theall, K. (2017). Separate and unequal: Structural racism and infant mortality in the US. Health & Place, 45, 140–144. https://doi.org/10.1016/j.healthplace.2017.03.012CrossRef

Wallace, M. E., Mendola, P., Liu, D., & Grantz, K. L. (2015). Joint effects of structural racism and income inequality on small-for-gestational-age birth. American Journal of Public Health, 105(8), 1681–1688. https://doi.org/10.2105/AJPH.2015.302613CrossRefPubMedPubMedCentral

Wanderer, J. P., Leffert, L. R., Mhyre, J. M., Kuklina, E. V., Callaghan, W. M., & Bateman, B. T. (2013). Epidemiology of obstetric-related ICU admissions in Maryland: 1999–2008. Critical Care Medicine, 41(8), 1844–1852. https://doi.org/10.1097/CCM.0b013e31828a3e24CrossRefPubMed

Wildeman, C. (2012). Imprisonment and (inequality in) population health. Social Science Research, 41(1), 74–91. https://doi.org/10.1016/j.ssresearch.2011.07.006CrossRefPubMed

Wildeman, C., & Wang, E. A. (2017). Mass incarceration, public health, and widening inequality in the USA. Lancet, 389(10077), 1464–1474. https://doi.org/10.1016/S0140-6736(17)30259-3CrossRefPubMed

Yearby, R. (2020). Structural racism and health disparities: Reconfiguring the social determinants of health framework to include the root cause. The Journal of Law, Medicine & Ethics, 48(3), 518–526. https://doi.org/10.1177/1073110520958876CrossRef

Yi, Y., Kennedy, J., Chazotte, C., Huynh, M., Jiang, Y., & Wildeman, C. (2021). Paternal jail incarceration and birth outcomes: Evidence from New York City, 2010–2016. Maternal and Child Health Journal, 25(8), 1221–1241. https://doi.org/10.1007/s10995-021-03168-6CrossRefPubMedPubMedCentral

Title: State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth
Publication date: 08-11-2023
Keyword: Hysterectomy
Published in: Maternal and Child Health Journal / Issue 1/2024
Print ISSN: 1092-7875
Electronic ISSN: 1573-6628
DOI: https://doi.org/10.1007/s10995-023-03828-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth

Abstract

Objectives

Methods

Results

Conclusions for Practice

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objectives

Methods

Results

Conclusions for Practice

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